What is a SIP

Coordinated Individual Plan is used to clarify who does what when multiple healthcare providers are involved in care. It is the individual's document and regulates the cooperation between different healthcare providers, for example, the hospital's specialized care, the doctor at the nursing home and nursing home staff.

Who can request a SIP

Those who receive help from both regional healthcare and municipally funded care and service have the right to request and receive a coordinated individual plan. Those who have the joint responsibility should in this case sit down together with the resident to jointly plan the care. In a nursing home, there may be this type of need, for example, in connection with discharge from the hospital when there are special needs for interventions such as rehabilitation.

For some residents, a SIP can be particularly valuable. This applies, for example, to people who need special rehabilitation after a stroke or who have a chronic disease such as ALS, Parkinson's or MS. Similarly, people who need help with tube feeding, care of a tracheostomy or other more advanced care. Likewise, people with psychiatric illness or treatment that requires follow-up by psychiatry, such as bipolar disorder.

For whom is the SIP made?

An important starting point when a SIP is made is that it should be based on the individual's needs. Studies have shown that the plan often is more based on the needs of care. Often, this is a reason for failure. Everyone believes they work person-centered, but if you ask the resident, you get a different picture. Not infrequently, staff and relatives talk while the elderly sit quietly on the side. Hearing loss and memory loss sometimes make the elderly excluded from the conversation.

The individual has the right to a SIP. It is statutory that municipal and regional care should cooperate around the individual when he or she has support from both organizations. For each patient, there should be a person in charge as a fixed healthcare contact. In a nursing home, it is often the doctor paid by the region who is the fixed healthcare contact, but the nurse often has a coordinating role and influences the doctor's schedule when he or she is at the nursing home. Yet, it often happens that a collaboration party claims they do not have time to participate in a SIP. They often think that the SIP is an extra step and that the individual still receives the care and service they should have.

Coordinated individual plan can also be a tool for collaboration in discharging patients from inpatient health and medical care. SIP should be established together with residents/patients if interventions from both social services and health and medical care need to be coordinated. The plan should clarify who does what and when.

The SIP plan belongs to the individual

Those who have participated in a SIP also have the right to have the joint plan printed on paper so that they can take part in it.

Reflection Questions - SIP
Care Staff:
- Do you ever get to participate in the creation of a SIP?
- In what situations can someone living with you get a SIP?

Manager, Nurse, Occupational Therapist, and Physiotherapist:
- Do you have residents with care and support interventions outside the residence?
- Have you conducted any SIP at the unit?
- Are there any obstacles to implementing a SIP?

Residents and relatives:
- Does your relative need a SIP as support?

Erland Olsson
Specialist nurse
Sofrosyne - Better care every day